Provider Demographics
NPI:1790185726
Name:MA, LI (LAC, DIPLOM)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:LAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2361 61ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2635
Mailing Address - Country:US
Mailing Address - Phone:646-515-2228
Mailing Address - Fax:
Practice Address - Street 1:2361 61ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-2635
Practice Address - Country:US
Practice Address - Phone:646-515-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003547171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist